|
Featured Questions
NOTE: Last Program Year for the Physician Quality Reporting System (PQRS)- 2016 was the last program year for the Physician Quality Reporting System (PQRS). PQRS was r... (more)
-
2016 was the last program year for the Physician Quality Reporting System (PQRS). PQRS was replaced by the Merit-based incentive Payment System (MIPS) under the new Quality Payment Program. The final data submission period for reporting 2016 PQRS quality data to avoid the 2018 PQRS downward payment adjustment was January through March 2017. The first MIPS performance period is January through December 2017. We encourage everyone to learn more about the Quality Payment Program by visiting qpp.cms.gov.
(FAQ20797)
less
What is the definition of "new patient" for billing evaluation and management (E/M) services?- Interpret the phrase... (more)
- Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. For example, if a professional component of a previous procedure is billed in a 3-year time-period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. The AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the Medicare Claims Processing Manual, chapter 26 (http://www.cms.gov/manuals/downloads/clm104c26.pdf). You may contact your Medicare claims processing contractor to confirm your primary Medicare specialty designation.
(FAQ1969)
less
How does Medicare pay for services delivered by non-participating providers?- For services and procedures performed by... (more)
- For services and procedures performed by non-participating fee-for service providers (i.e., those providers who opt out of Medicare assignment), the total Medicare allowed amounts for servicers and procedures are slightly lower (5% lower) compared to Medicare allowed amounts for participating providers. However, while participating providers can only charge Medicare beneficiaries a coinsurance amount up to 20% of the Medicare allowed amount, non-participating providers can charge beneficiaries the 20% coinsurance plus an additional amount up to a total of 115% of their reduced allowed amount (this is referred to as the limiting charge portion).
(FAQ9920)
less
Who is eligible to receive an NPI?- The National Provider Identifier (NPI) was adopted and became effective May 23, 2007 as the standard unique health ident... (more)
- The National Provider Identifier (NPI) was adopted and became effective May 23, 2007 as the standard unique health identifier for health care providers to carry out a requirement in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for the adoption of such a standard. An entity who meets the definition of a “health care provider” – that is, any provider of medical or other health services, and any other person or organization that furnishes, bills, or is paid for health care in the normal course of business – is eligible to receive a provider ID, or NPI. Under HIPAA, a covered health care provider is any provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted. These covered health care providers must obtain an NPI and use this number in all HIPAA transactions, in accordance with the instructions in the adopted Implementation Guides/TR3 Reports. The NPI may also be used on paper claims, but HIPAA does not govern that method of submitting claims.
In general, health care providers include hospitals, nursing homes, ambulatory care facilities, durable medical equipment suppliers, clinical laboratories, pharmacies, and many other “institutional” type providers; physicians, dentists, psychologists, pharmacists, nurses, chiropractors and many other health care practitioners and professionals; group practices, health maintenance organizations, and others. For more information and white papers about health care providers, including atypical providers, visit the CMS website at: http://www.cms.hhs.gov/NationalProvIdentStand/.
(FAQ1849)
less
Who can enter medication orders in order to meet the measure for the computerized provider order entry (CPO...- As mentioned in 80 FR 62798, a medical staff person who is a credentialed medica... (more)
- As mentioned in 80 FR 62798, a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant may enter orders. We maintain our position that medical staff must have at least a certain level of medical training in order to execute the related CDS for a CPOE order entry. We defer to the provider to determine the proper credentialing, training, and duties of the medical staff entering the orders as long as they fit within the guidelines we have proscribed. We believe that interns who have completed their medical training and are working toward appropriate licensure would fit within this definition. We maintain our position that, in general, scribes are not included as medical staff that may enter orders for purposes of the CPOE objective. However, we note that this policy is not specific to a job title but to the appropriate medical training, knowledge, and experience. For more information about the Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10134
Date Updated: 05/12/2016
(FAQ2851)
less
What physician shared patient data sets are available?- The physician referral data linked below was provided as a response to a Freedom of
Information Act (FOIA) request. The... (more)
- The physician referral data linked below was provided as a response to a Freedom of
Information Act (FOIA) request. These files represent the number of encounters
a single beneficiary has had across physicians at intervals of 30, 60, 90 and
180 days. For more details about the file contents for years 2009 - 2015,
please see the Technical Requirements document: http://downloads.cms.gov/foia/Physician_Shared_Patient_Patterns_Technical_Requirements.pdf
Note: The files range in size from 1-7 gigabytes. Special statistical software is needed for analysis. These files will not fully open in a text editor or Microsoft Excel.
(FAQ7977)
less
If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the healt...- Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of ... (more)
- Yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the internet (https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart) or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services' forms page (www.cms.hhs.gov/cmsforms) or may call the NPI Enumerator (1-800-465-3203) and request a form.
(FAQ1859)
less
Who pays the difference between what the provider charges and Medicare pays?- The provider has an ... (more)
- The provider has an agreement with Medicare to accept Medicare’s payment and the difference is not paid by Medicare or any other entity, including the beneficiary.
(FAQ9264)
less
What can count as a specialized registry?- A submission to a specialized registry may count if the receiving entity meets t... (more)
- A submission to a specialized registry may count if the receiving entity meets the following requirements: The receiving entity must declare that they are ready to accept
data as a specialized registry and be using the data to improve population
health outcomes. Most public health agencies and clinical data
registries are declaring readiness via a public online posting.
Registries should make this information publically available for potential
registrants. The receiving entity must also be able to receive electronic
data generated from CEHRT. The electronic file can be sent to the
receiving entity through any appropriately secure mechanism including, but not
limited to, a secure upload function on a web portal or Direct. Manual
data entry into a web portal would not qualify for submission to a specialized
registry. The receiving entity should have a registration of intent
process, a process to take the provider through test and validation and a
process to move into production. The receiving entity should be able
to provide appropriate documentation for the sending provider or their current
status in Active Engagement. For qualified clinical data registries, reporting to a QCDR may count for the public health specialized registry measure as long as the submission to the registry is not only for the purposes of meeting CQM requirements for PQRS or
the EHR Incentive Programs; In other words, the submission may count if
the registry is also using the data for a public health purpose. Many
QCDRs use the data for a public health purpose beyond CQM reporting to
CMS. A submission to such a registry would meet the requirement for the
measure if the submission data is derived from CEHRT and transmitted
electronically. CMS has developed a centralized repository for public
health agency and clinical data registry reporting to provide an additional,
centralized source of information for eligible professionals, eligible
hospitals, and critical access hospitals looking for public health, clinical
data, or specialized registry electronic reporting options.
Created 12/11/2015
Updated 03/13/2017
(FAQ13653)
less
What is a Medically Unlikely Edit?- A MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Co... (more)
- A MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. MUEs are adjudicated either as claim line edits or date of service edits. The MUE program provides a method to report medically reasonable and necessary UOS in excess of an MUE for MUEs that are adjudicated as claim line edits. (See separate FAQ #2277 for guidance on reporting medically reasonable and necessary services in excess of an MUE value.) If an MUE is adjudicated as a claim line edit or a date of service edit, UOS in excess of the MUE value may be paid during the appeal process. (See separate FAQ #11344 for information about date of service MUEs.)
(FAQ2273)
less
EHR Incentive Programs; What should a provider do in 2016 if they did not previously intend to report to a ...- ... (more)
- In the 2015 EHR Incentive Programs Final Rule, we stated that we
did not intend for providers to be inadvertently penalized for changes to their
systems or reporting made necessary by the provisions of that regulation.
This included alternate exclusions for providers for certain measures in 2016 which
might require the acquisition of additional technologies they did not
previously have for measures they did not previously intend to include in their
activities for meaningful use (80 FR 62945).Therefore, in order that
providers are not held accountable to obtain and implement new or additional
systems, we will allow providers to claim an alternate exclusion from certain
public health reporting measures in 2016 if they did not previously intend to
report to the Stage 2 menu measure.
LIST OF MEASURES FOR EPs WHICH WOULD ALLOW AN ALTERNATE
EXCLUSION: Public Health Reporting measure 2 (Syndromic surveillance) and measure 3 (specialized registry). LIST OF MEASURES FOR EHs WHICH WOULD ALLOW AN ALTERNATE
EXCLUSION Public Health Reporting measure 3 (specialized registry)
Created 02/25/2016 Updated 01/11/2017
(FAQ14397)
(FAQ14397)
less
What is the difference between a legacy provider identifier (LPI) and a National Provider Identifier (NPI)?...- LPIs are any of a known set of identifie... (more)
- LPIs are any of a known set of identifiers used by either states or the federal government to identify service providers prior to the arrival of National Provider Identifiers (NPIs). LPIs can be state-specific provider IDs, Medicare Provider Identification Number (PIN), Medicare Unique Physician Identification Number (UPIN), Online Survey Certification and Reporting (OSCAR) IDs, Medicare National Supplier Clearinghouse (NSC) numbers, other Medicare IDs of unknown type, as well as other commercial numbering systems. NPIs are a unique, 10-digit, sequentially assigned national identification number that are mandated by HIPAA to be used by health care providers, health plans, and health care clearinghouses in all administrative and financial HIPAA transactions. NPIs are routinely assigned only to medical providers. There are many non-medical providers serving Medicaid enrollees (e.g. home care services and transportation) that do not usually receive NPIs. So, all Medicaid providers have some types of LPIs, but not all Medicaid providers have NPIs. CMS began collecting NPIs in MSIS data in Fiscal 2009, although reporting was not complete for medical providers initially. NPIs have been captured in MAX to the extent they are available, beginning with 2009 data.
(FAQ6115)
less
What is the column 1/column 2 correct coding edit table?- The column 1/column 2 correct coding edit table contains two types of code pair edits. One type cont... (more)
- The column 1/column 2 correct coding edit table contains two types of code pair edits. One type contains a column 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code which is an integral part of the column 1 HCPCS/CPT code. The other type contains code pairs that should not be reported together where one HCPCS/CPT code is assigned as the column 1 code and the other HCPCS/CPT code is assigned as the column 2 code. If two codes of a code pair edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 HCPCS/CPT code is paid. If clinical circumstances justify appending a National Correct Coding Initiative (NCCI)-associated modifier to the column 2 HCPCS/CPT code of a code pair edit, payment of both HCPCS/CPT codes may be allowed if the modifier indicator is "1".
(FAQ11238)
less
If an eligible provider fails to meet meaningful use (MU) during a participation year in the Medicare Elect...- An Eligible Professional (EP), Eligible Hospital or Critical Access Hospital (CAH) that participates in the Medicare EHR... (more)
- An Eligible Professional (EP), Eligible Hospital or Critical Access Hospital (CAH) that participates in the Medicare EHR Incentive Program and does not meet MU for one participation year is highly encouraged to continue to attest and earn incentive payments for future participation years.
If a participating provider does not successfully attest for a given year, he/she will not be eligible to receive an incentive payment for that year. However, attesting and receiving an incentive payment for a future participation year is based on the provider’s ability to meet MU during that year and not based on success or failure in previous years.
When a provider continues to participate and submit attestation information in subsequent years, the progression through the stages of MU will continue to follow the CMS-established timeline of meeting the MU criteria of each stage for two program years, regardless of whether he/she demonstrates MU in each consecutive year.
For example, if an EP demonstrates the stage 1 criteria for the 1st payment year, but does not meet the stage 1 criteria in the 2nd payment year, the EP will receive an incentive payment for the 1st payment year but not receive the associated incentive payment for the 2nd year.
When the EP proceeds to attest for the 3rd payment year, he/she may be eligible to receive the associated incentive payment if MU is met. However, since the EP has completed the 1st and 2nd program years, the EP will be expected to demonstrate the stage 2 meaningful use criteria to receive payment in the 3rd year, even if he/she did not meet the stage 1 criteria in the 2nd year.
If a provider registers to participate in the EHR Incentive Program for the first year but chooses to withdraw their attestation, the provider may have the opportunity to start over and “repeat” their first year of participation in the Incentive Program if a CMS post payment or prepayment audit has not been initiated. If the provider withdraws their attestation during or after a CMS audit has been conducted, the provider forfeits the ability to reattest as a Year 1 participant and must attest as a Year 2 participant in the next year. Once the provider has withdrawn and the audit has been initiated, the progression along the EHR Incentive Program timeline has begun and the provider would need to meet MU along this schedule in order to earn the associated incentive payments.
Please see title=https://questions.cms.gov/reps/faq.php?faqId=7737" target=FAQ 7737 for information about the meaningful use progression in the Medicaid EHR Incentive Program.
For more information about the EHR Incentive Program timeline, please visit http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html To use the interactive “My EHR Participation Timeline” tool, please visit: http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Participation-Timeline.html
(FAQ9220)
less
Which Healthcare Provider Taxonomy Code(s) should be selected by medical students, interns, residents and f...- The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transactions to indicate h... (more)
- The Healthcare Provider Taxonomy Code set is a code set which may be used in certain standard transactions to indicate health care provider type, classification, and/or specialization. A healthcare provider must select a Healthcare Provider Taxonomy Code from this code set when applying for a National Provider Identifier (NPI). The code set is maintained by the National Uniform Claim Committee (NUCC) and is made available to the public by the Washington Publishing Company (WPC). Information on requesting changes to the code set is available from the NUCC (www.nucc.org/). Frequently Asked Questions and information on printing or downloading the code set is available from the WPC (www.wpc-edi.com ).
All covered health care providers are eligible for NPIs and may apply for them. Because they are health care providers, medical students, interns, residents, and fellows are eligible for NPIs. If they do not transmit any health data in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard, they are not “covered” health care providers under HIPAA and are not required by the NPI Final Rule to obtain NPIs. If they do, however, they would be covered health care providers and they must get NPIs.• A Healthcare Provider Taxonomy Code for classifying medical students, and interns and residents who are not yet licensed (based on state licensing requirements), is available for use: Student, Health Care (390200000X). The code is defined as follows: An individual who is enrolled in an organized health care education/training program leading to a degree, certification registration, and/or licensure to provide health care. Medical students, interns, and residents who are not licensed should select the Student, Health Care code when applying for NPIs.• Once licensed as an allopathic or osteopathic physician, the physician should update his/her data in the National Plan and Provider Enumeration System (NPPES) by submitting a change in the Healthcare Provider Taxonomy Code to reflect the change in status from medical student to physician. (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change).• If physicians who have been assigned NPIs become board-certified in other specialties or subspecialties, the physicians should update his/her data in the NPPES with these changes or additions in their specializations (i.e., they would indicate the changes or additions by changing their Healthcare Provider Taxonomy Codes). (If they are “covered” health care providers, they are required to do so, and any such change must be provided to the NPPES within thirty days of the change.)
(FAQ1947)
less
I entered numerator and denominator information during my Medicare Electronic Health Record (EHR) Incentive...- CMS does not plan to conduct an audit to find providers who relied on flawed software for their atte... (more)
- CMS does not plan to conduct an audit to find providers who relied on flawed software for their attestation information. We realize that providers relied on the software they used for accuracy of reporting, and we believe that most providers who were improperly deemed meaningful users would have met the requirements of the EHR Incentive Programs using the updated certified EHR technology.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ22001
(FAQ6097)
less
What steps does a provider have to take to determine if there is a specialized registry available for them,...- The eligible professional (EP) is not required to make an exhaustive search of all potential registries. Instead, they ... (more)
- The eligible professional (EP) is not required to make an exhaustive search of all potential registries. Instead, they must do a few steps to meet due diligence in determining if there is a registry available for them, or if they meet the exclusion criteria.
1 – An EP should check with their State* to determine if there is an available specialized registry maintained by a public health agency.
2 – An EP should check with any specialty society with which they are affiliated to determine if the society maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider’s EHR reporting period.
If the EP determines no registries are available, they may exclude from the measure.
For EPs: The provider may meet the specialized registry measure up to 2 times. This can be done through reporting to:
Two registries maintained by a public health agency
Two registries maintained by one or more specialty societies
One registry maintained by a public health agency and one maintained by a specialty society
One registry maintained by a public health agency and one exclusion
One registry maintained by a specialty society and one exclusion
Two exclusions
PLEASE NOTE: In 2015, providers may also simply claim an alternate exclusion for a measure as defined in FAQ 12985.
*If you report to an entity other than a State as your reporting jurisdiction (such as a county) you may elect to check with them.
Created 12/11/2015
Updated 02/25/2016
(FAQ13657)
less
In calculating the meaningful use objectives and measures for View, Download and Transmit, Secure Electroni...- The transitive effect applies to the View, Download and Transmit measure, Secure Electronic Messaging measure and to the... (more)
- The transitive effect applies to the View, Download and Transmit measure, Secure Electronic Messaging measure and to the Patient Specific Education measure. If a provider initiates or responds to a patient’ secure message about a clinical or health related subject to on behalf of the group practice or care team , that patient can be counted in the numerator of the Secure Electronic Messaging measure for any of the EPs at the group practice or part of the care team who use the same certified electronic health records technology (CEHRT) that saw the patient during their EHR reporting period. Similarly, if a patient views, downloads or transmits to a third party the health information that was made available online by their EP, that patient can be counted in the numerator for any of the EPs in that group practice or part of the care team who use the same CEHRT and saw that patient during their EHR reporting period. If patient-specific education resources are provided electronically, it may be counted in the numerator for any provider within the group or part of the care team sharing the CEHRT who has contributed information to the patient's record if that provider has the patient in their denominator for the EHR reporting period.
We clarify that: if it is not possible to determine who provided the health information, or multiple providers in the group practice (or part of the care team) saw the patient during their EHR reporting period or multiple providers contributed information to the patient’s record and those providers have the patient in their denominator for the EHR reporting period then the patient can be counted in the numerator of the applicable measure(s) for those providers. We note that this could include all providers who share the same CEHRT and saw the patient during the reporting period.”
(FAQ12825)
less
I have a Drug Enforcement Administration (DEA) Number. Do I need a National Provider Identifier (NPI) as well?- The NPI does not replace the function of the DEA Number, which is to identify the prescriber of a controlled or dangerou... (more)
- The NPI does not replace the function of the DEA Number, which is to identify the prescriber of a controlled or dangerous substance. The NPI was adopted to identify a health care provider as a health care provider in standard transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A health care provider who is a covered entity under HIPAA is required to obtain an NPI, and to use that NPI to identify itself as a health care provider in HIPAA standard transactions. Health care providers who are not covered entities under HIPAA, but who prescribe medications, order services for patients, refer patients to other providers, or who otherwise need to be identified in HIPAA standard transactions that are conducted by other health care providers, will need (but are not required) NPIs so that those other health care providers can use that number to identify them in the HIPAA standard transactions that they conduct. The definition for a HIPAA covered health care provider may be found at 45CFR 162.103.
(FAQ2091)
less
What is the policy for measure calculation for actions
outside of the EHR reporting period for the Medicar...- ... (more)
- In the 2017 OPPS/ASC final rule we finalized changes for meaningful use measures (unless otherwise specified), actions included in the numerator must occur within the EHR reporting period if that period is a full calendar year, or if it is less than a full calendar year, within the calendar year in which the EHR reporting period occurs. Meaning that all actions in the numerator must occur between January 1st and December 31st for all calendar years beginning in 2017.
The following objectives and measures fall under this policy in 2017 for Modified Stage 2: - Protect Patient Health Information: (Security Risk Analysis),
- Health Information Exchange,
- Patient Specific Education,
- Patient Electronic Access (measure 2 - VDT)
- Secure Messaging (EPs only for Modified Stage 2), and
The following objectives and measures fall under this policy
for Stage 3: - Protect Patient Health Information (Security Risk Analysis),
- Patient Electronic Access to Health Information (measure 2-Patient Specific Educational
Resources),
- Coordination of Care Through Patient Engagement (measure 1 – VDT and measure 2-
Secure Messaging)
- Health Information Exchange (measure 1 – Send a Summary of Care), and
For more information specific to the Security Risk Assessment, see FAQ #13649. Please note that beginning in 2017, the security risk assessment must be conducted within the calendar year in which the EHR reporting period occurs.
For more information specific to numerator calculations for actions outside the EHR reporting period for the Medicare and Medicaid EHR Incentive Programs prior to 2017, see FAQ # 8231.
(FAQ18261)
less
How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit ...- For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, each line of a claim i... (more)
- For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. The appropriate use of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service) will accomplish this purpose. Modifier 59 may be utilized only if no other appropriate modifier describes the service. For MUEs that are adjudicated as date of service edits, units of service (UOS) in excess of the MUE value may be paid during the appeal process. (See separate FAQ for information about date of service MUEs.)
(FAQ11352)
less
Are payments provided to a consulting firm or third party, whom in turn provide the payment (in whole or pa...- Yes, Open Payments requires reporting of both direct and indirect payments and other transfers of value provided by an a... (more)
- Yes, Open Payments requires reporting of both direct and indirect payments and other transfers of value provided by an applicable manufacturer or applicable group purchasing organization to a covered recipient. An indirect payment is a payment or transfer of value made by an applicable manufacturer, or an applicable group purchasing organization, to a covered recipient, or a physician owner or investor, through a third party, where the applicable manufacturer, or applicable group purchasing organization, requires, instructs, directs, or otherwise causes the third party to provide the payment or transfer of value, in whole or in part, to a covered recipient(s), or a physician owner or investor. Key words: Open Payments, Sunshine Act
(FAQ8155)
less
Can hospitals bill Medicare for the lowest level ER visit for patients who check into the ER and are "triag...- No. The limited service provided to such... (more)
- No. The limited service provided to such patients is not within a Medicare benefit category because it is not provided incident to a physician's service. Hospital outpatient therapeutic services and supplies (including visits) must be furnished incident to a physician's service and under the order of a physician or other practitioner practicing within the extent of the Act, the Code of Federal Regulations, and State law. Therapeutic services provided by a nurse in response to a standing order do not satisfy this requirement.
(FAQ2297)
less
How do I change the laboratory director's name on my CLIA certificate of waiver?- You must notify the appropriate State Agency within 30 days about the change in the name of the director for your CLIA c... (more)
- You must notify the appropriate State Agency within 30 days about the change in the name of the director for your CLIA certificate. State Agency contact information is found on the CMS CLIA internet page at http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf
(FAQ12554)
less
Does CMS require updated physician (or non-physician practitioner) orders for lab, radiology services, or a...- CMS is not requiring the ordering provider to rewrite the or... (more)
- CMS is not requiring the ordering provider to rewrite the original order with the appropriate ICD-10 code for lab, radiology services, or any other services after ICD-10 implementation on October 1, 2015, including Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
Products and services that require a diagnosis code on the order will use ICD-9-CM codes if written prior to October 1, 2015. If the order is for a repetitive service that will continue to be delivered and billed after October 1, 2015, providers have the option to use the General Equivalence Mappings (GEMs) posted on the 2016
ICD-10-CM and GEMs web page to translate the ICD-9-CM codes on the
original order into ICD-10-CM diagnosis codes.
(FAQ12625)
less
Do Current Procedural Terminology (CPT) codes for psychological and neuropsychological tests include tests ...- Yes. Effective Janu... (more)
- Yes. Effective January 1, 2006, CPT codes for psychological and neuropsychological tests include tests performed by technicians and computers (CPT codes 96102, 96103, 96119 and 96120) in addition to tests performed by physicians, clinical psychologists (CPs), independently practicing psychologists (IPPs) and other qualified nonphysician practitioners (NPPs). The payment amounts for tests performed by a technician or a computer are adjusted depending upon whether the service was performed in a facility or non-facility setting.
(FAQ2415)
less
The billing provider on a claim is an eligible professional (EP) but the performing provider type is not an...- In establishing an encounter for purposes of patient volume, please see the regulations at 495.306(e... (more)
- In establishing an encounter for purposes of patient volume, please see the regulations at 495.306(e)(2)(i)-(ii) at 75 FR 44579. Furthermore, in estimating patient volume for any EP or hospital, we do not specify any requirements around billing, but rather we discuss patients. For example, if a physician’s assistant (PA) provides services, but they are billed through the supervising physician, it seems reasonable that a State has the discretion to consider the patient as part of the patient volume for both professionals. However, this policy would need to be applied consistently. In this scenario, using services provided by the PA but billed under the physician in the physician’s numerator (e.g., Medicaid encounters) also would increase the physician’s denominator (all encounters), because the State would need to adequately reflect the total universe of patients (both Medicaid and non-Medicaid) who the PA saw, but for whom the physician billed.In terms of meaningful use, because each eligible professional must demonstrate meaningful use of certified EHR technology him or herself, if the State cannot not distinguish between the physician’s claims and the PA’s individual claims, then this would not be an adequate audit methodology. To view the final rule, please visit: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10098
(FAQ2817)
less
What is the difference between a health plan and a payer?- A health plan (as defined in ... (more)
- A health plan (as defined in 45 CFR 160.103) is an individual plan or group health plan that provides or pays the cost of medical care. The term “payer” is an industry term and may include a health plan, but may also designate other entities that do not meet the definition of a health plan, such as a third party administrator (TPA).
(FAQ10692)
less
Is the physician the only person who can enter information in the electronic health record (EHR) in order t...- The Stage 3 Final Rule for the Medicaid EHR incentive programs specifies that in... (more)
- The Stage 3 Final Rule for the Medicaid EHR incentive programs specifies that in order to meet the meaningful use objective for computerized provider order entry (CPOE), any licensed health care provider or a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant can enter orders in the medical record, per state, local and professional guidelines. The remaining meaningful use objectives do not specify any requirement for who must enter information.
For more information about the Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10071
Date Updated: 05/12/2016
(FAQ2771)
less
A number of measures for Meaningful Use objectives for eligible hospitals and critical access hospitals (CA...- There are two methods for calculating ED admissions for the denominators for measures associated wit... (more)
- There are two methods for calculating ED admissions for the denominators for measures associated with Meaningful Use objectives. Eligible hospitals and CAHs must select one of the methods below for calculating ED admissions to be applied consistently to all denominators for the measures. That is, eligible hospitals and CAHs must choose either the "Observation Services method" or the "All ED Visits method" to be used with all measures. Providers cannot calculate the denominator of some measures using the "Observation Services method," while using the "All ED Visits method" for the denominator of other measures. Before attesting, eligible hospitals and CAHs will have to indicate which method they used in the calculation of denominators (77 FR 53984).Observation Services method. When using this method, the denominator should include the following visits to the ED: The patients who are admitted to the inpatient department (Place of Service (POS) 21) either directly or through the emergency department.The patients who are initially presented to the emergency department (POS 23) and receive observation services. Patients who receive observation services under both POS 22 and POS 23 should be included in the denominator. Details on observation services can be found in the Medicare Benefit Policy Manual, Chapter 6, Section 20.6.All ED Visits method. An alternate method for computing admissions to the ED is to include all ED visits (POS 23 only) in the denominator for all measures requiring inclusion of ED admissions. All actions taken in the inpatient or emergency departments (POS 21 and 23) of the hospital would count for purposes of determining meaningful use. For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
5/12/2016
(FAQ2843)
less
What is the value-based payment modifier (Value Modifier) and who does it apply to?- The Affordable Care Act requires Medicare to establish a Value Modifier that provides for differential payment to a phys... (more)
- The Affordable Care Act requires Medicare to establish a Value Modifier that provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule (PFS) based upon the quality of care furnished to Medicare beneficiaries compared to the cost of that care during a performance period. Further, the statute requires that we begin applying the Value Modifier on January 1, 2015, with respect to items and services furnished by specific physicians and groups of physicians (as
determined by the Secretary) and to apply it to all physicians and groups of
physicians beginning not later than January 1, 2017. The statute requires that
payments made under the Value Modifier must be budget neutral meaning that
upward payment adjustments for high performance must balance the downward
payment adjustments applied for poor performance. The 2018 Value Modifier is
based on 2016 performance, and it will apply to payments to physicians,
physician assistants, nurse practitioners, clinical nurse specialists, and
certified registered nurse anesthetists, for items and services furnished under
the Medicare Physician Fee Schedule.
(FAQ10262)
less
How is hospital-based status determined for eligible professionals in the Medicaid Electronic Health Record...- A hospital-based eligible professional (EP) is defined as an EP who furnishes 90... (more)
- A hospital-based eligible professional (EP) is defined as an EP who furnishes 90% or more of their covered professional services in either the inpatient (Place of Service 21) or emergency department (Place of Service 23) of a hospital. Covered professional services are physician fee schedule (PFS) services paid under Section 1848 of the Social Security Act. CMS uses PFS data from the Federal fiscal year immediately preceding the calendar year for which the EHR incentive payment is made (that is, the "payment year") to determine what percentage of covered professional services occurred in either the inpatient (Place of Service 21) or emergency department (Place of Service 23) of a hospital. The percentage determination is made based on total number of Medicare allowed services for which the EP was reimbursed, with each unit of a CPT billing code counting as a single service. States will use claims and/or encounter data (or equivalent data sources at the State's option) to make this determination for Medicaid. States may use data from either the prior fiscal or calendar year. For the Medicaid EHR Incentive Program, EPs should contact their states for more information. For more information about the Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
Keywords: FAQ10464
(FAQ3061)
less
When eligible professionals work at more than one clinical site of practice, are they required to use data ...- CMS considers these two separate, but related issues. Meaningful use: Any eligible professional demo... (more)
- CMS considers these two separate, but related issues. Meaningful use: Any eligible professional demonstrating meaningful use must have at least 50% of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives. Therefore, States should collect information on meaningful users' practice locations in order to validate this requirement in an audit. Patient volume ;Eligible professionals may choose one (or more) clinical sites of practice in order to calculate their patient volume. This calculation does not need to be across all of an eligible professional's sites of practice. However, at least one of the locations where the eligible professional is adopting or meaningfully using certified EHR technology should be included in the patient volume. In other words, if an eligible professional practices in two locations, one with certified EHR technology and one without, the eligible professional should include the patient volume at least at the site that includes the certified EHR technology. When making an individual patient volume calculation (i.e., not using the group/clinic proxy option), a professional may calculate across all practice sites, or just at the one site. For more information on applying the group/clinic proxy option, see FAQ #10362 or http://questions.cms.hhs.gov/app/answers/detail/a_id/10362/kw/group%20practice/session/For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
FAQ10416
(FAQ3015)
less
Who are the current Medicare Administrative Contractors (MACs) for each Jurisdiction?- To find the current MACs and their contact information visit the CMS.gov website at: ... (more)
- To find the current MACs and their contact information visit the CMS.gov website at: Who are the MACs.
(FAQ14833)
less
If an applicable manufacturer or applicable group purchasing organization (GPO) provides a payment or trans...- No, this payment or other transfer of value would not be reportable because it does not meet the def... (more)
- No, this payment or other transfer of value would not be reportable because it does not meet the definition of an indirect payment as defined at 42 U.S.C. § 403.902. For example, if an applicable manufacturer or GPO provides payments to a continuing education provider that are unrestricted and are intended to be used at the organization’s full discretion, and the organization chooses on its own volition to use those funds to pay physician speakers, the applicable manufacturer or GPO would not be required to report the payments or transfers of value. These payments are not reportable regardless of whether the applicable manufacturer or GPO learns that the payments went to covered recipient physicians and the identity of the physicians during the reporting year or by the end of the second quarter of the following reporting year because they would not meet the definition of an indirect payment.
Key words: Open Payments, Sunshine Act, CME, Physician Fee Schedule
(FAQ8165)
less
While the denominator for measures used to calculate meaningful use in the Medicare and Medicaid Electronic...- ... (more)
- The criteria for a numerator is not constrained to the EHR reporting period unless expressly stated in the numerator statement for a given meaningful use measure. The numerator for the following meaningful use measures should include only actions that take place within the EHR reporting period: Preventive Care (Patient Reminders) and Secure Electronic Messaging.For all other meaningful use measures, the actions may reasonably fall outside the EHR reporting period timeframe but must take place no earlier than the start of the reporting year and no later than the date of attestation in order for the patients to be counted in the numerator, unless a longer look-back period is specifically indicated for the objectives or measure. For program year 2015 and subsequent years, the requirements have been defined in the final rule (80 FR 62792). For more information specific to the Security Risk Assessment in 2015 and subsequent years, see FAQ #13649 https://questions.cms.gov/faq.php? Created on 4/26/2013
Updated on 6/23/2014
Updated on 9/24/2015
Updated on 12/11/2015
Updated on 12/14/2015
(FAQ8231)
less
What is HETS and how do I get connected to use this system?- The HIPAA Eligibility Transaction System (HETS) is intended ... (more)
- The HIPAA Eligibility Transaction System (HETS) is intended to allow the release of eligibility data to Medicare providers or their authorized billing agents for the purpose of preparing an accurate Medicare claim, determining beneficiary liability, or determining eligibility for specific services. Such information may not be disclosed to anyone other than the provider, supplier, or beneficiary for whom a claim is filed. The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.The data included in a 271 response file is to be considered true and accurate only at the particular time of the transaction. The HETS 270/271 application provides access to Medicare Beneficiary eligibility data in a real-time environment. In real-time mode, the Trading Partner transmits a 270 request and remains connected while the receiver processes the transaction and returns a 271 response. Providers, Clearinghouses, and/or Third Party Vendors, herein referred to as “Trading Partners”, may initiate a real-time 270 eligibility request to query coverage information from Medicare on patients for whom services are scheduled or have already been delivered.
Please refer to the HETS 'How To Get Connected' page on the cms.gov website for additional information on how to obtain a connection to, and then apply for, HETS access. Please contact the Help Desk if you have any questions. Call: 1-866-324-7315 . You can also email the help desk at mcare@cms.hhs.gov. This email address is monitored Monday - Friday 7AM - 7PM ET. Emails are typically answered within 24-48 business hours.
(FAQ2151)
less
Starting with 2016 Open Payments data collection and reporting to CMS in 2017, are payments provided by an ...- Yes, the payment is reportable if the applicable manufacturer determines that the payment meets the definition of an ind... (more)
- Yes, the payment is reportable if the applicable manufacturer determines that the payment meets the definition of an indirect payment, and the applicable manufacturer knows or can determine the identity of the covered recipient by the end of the second quarter of the following reporting year. An indirect payment is defined at 42 C.F.R. §403.902 as a payment or other transfer of value made by an applicable manufacturer to a covered recipient through a third party, where the applicable manufacturer requires, instructs, directs, or otherwise causes the third party to provide the payment or transfer of value, in whole or in part, to a covered recipient. In accordance with 42 C.F.R. §403.904(i)(1), indirect payments or other transfers of value do not have to be reported if the applicable manufacturer is unaware of the identity of the covered recipient during the reporting year or by the end of the second quarter of the following reporting year. Keywords: Open Payments, Sunshine Act, CME, Physician Fee Schedule
(FAQ11638)
less
How are claims adjudicated with Medically Unlikely Edits (MUEs)?- Medically Unlikely Edits (MUEs) are either claim line edits or date of service (DOS) edits. If the MUE is a claim line e... (more)
- Medically Unlikely Edits (MUEs) are either claim line edits or date of service (DOS) edits. If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code on that claim line. If the units of service (UOS) on the claim line exceeds the MUE value, all UOS for that claim line are denied. If the same code is reported on more than one line of a claim by using CPT modifiers, each line of the claim is adjudicated separately against the MUE value of the code on that claim line.
If the MUE is a date of service MUE, all UOS for the HCPCS/CPT code reported by the same provider for the same beneficiary for the same date of service are summed. The summed value is compared to the MUE value. If the sum is greater than the MUE value, all UOS for the code on the current claim are denied.
(FAQ11344)
less
What types of business structures are considered organization health care providers and thus eligible for o...- The NPI final rule defines “organization health care providers” as providers who are not individuals (persons). Thes... (more)
- The NPI final rule defines “organization health care providers” as providers who are not individuals (persons). These are classified as Entity Type 2 providers. Examples are hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, health maintenance organizations, suppliers of durable medical equipment or pharmacies, among others.
Some health care provider organizations are made up of components or business units that function somewhat independently of the ”parent” health care organization of which they are a part. These components, which are referred to as “subparts” in the regulation, might conduct their own standard transactions, might be at the same or at a different address than the organization provider “parent”, might furnish a type of service different from the organization provider “parent.” These subparts or business units might be required by Federal regulations to have unique identifiers for billing purposes. Each organization must make a determination regarding the status of its subparts, and apply for NPIs as it deems appropriate. The Work group for Electronic Data Exchange (WEDI) has a white paper on this topic that can be helpful for covered entities in making their decisions.
A sole proprietorship is a form of business in which one person owns all of the assets of the business and is solely liable for all debts on an individual basis. Sole proprietors are individuals, and they must apply for their NPIs as Individuals (Entity Type I). The subpart concept does not apply to a sole proprietorship, even one with multiple locations, because the sole proprietorship is not an organization as defined in the Final NPI Rule (69FR3434).
State laws enable the creation of many other different types of businesses. While we cannot address every possible type of business structure, we apply the following broad principle to determine whether a business is eligible for an organization NPI: Any organization that is recognized by the State as separate and distinct from the individual is eligible for an organization NPI. The law in each State will govern how different business types are recognized by the State.
(FAQ1965)
less
What are the supervision requirements for diagnostic psychological and neuropsychological tests?- Under the diagnostic test provision as a... (more)
- Under the diagnostic test provision as authorized under Medicare law at section 1861(s)(3) of the Social Security Act (the Act) and interpreted under regulations at 42 CFR 410.32, all diagnostic tests are assigned a certain level of supervision. Generally, regulations governing the provision of diagnostic tests require a physician to provide the appropriate level of supervision for such tests. That is, the physician must either provide general, direct, or personal supervision.
However, for diagnostic psychological and neuropsychological tests (96101-96120), there is a regulatory exception at 42 CFR 410.32(b)(2)(iii) that allows either a clinical psychologist (CP) or a physician to provide the required general supervision for diagnostic psychological and neuropsychological tests. Moreover, nonphysician practitioners (NPPs) such as nurse practitioners (NPs) and clinical nurse specialists (CNSs) under 42 CFR 410.32(b)(2)(B)(v), and physician assistants (PAs) under 42 CFR 410.32(b)(3) who personally perform diagnostic psychological and neuropsychological tests are excluded from the supervision requirements for diagnostic tests. However, they must meet the collaboration and physician supervision practice requirements under their respective benefits.
(FAQ2417)
less
Are new participants that attest only to the Medicaid EHR
Incentive Program in 2017 required to attest to ...- In the 2017 OPPS/ASC final rule,we stated that time and cost limitation concerns related to the 2015 Edition upgrades ma... (more)
- In the 2017 OPPS/ASC final rule,we stated that time and cost limitation concerns related to the 2015 Edition upgrades made it unfeasible for EPs, eligible hospitals, and CAHs that have not successfully demonstrated meaningful use in a prior year (new participants) to
attest to the Stage 3 objectives and measures in 2017 in the EHR Incentive
Program Registration and Attestation System. We finalized that for CY 2017, EPs
and eligible hospitals that have not successfully demonstrated meaningful use
in a prior year and are seeking to avoid the 2018 payment adjustment or any CAH
that has not successfully demonstrated meaningful use in a prior year and is
seeking to avoid the 2017 payment adjustment would have to attest to Modified
Stage 2 objectives and measures. This requirement is specific to EPs, eligible
hospitals and CAHs who attest to CMS through the EHR Incentive Program
Registration and Attestation system. In the final rule we stated that this
change would apply to Medicaid providers who usually attest to their State.
This change, however, does not apply to Medicaid providers who attest to their
State, only new participants who are dual-eligible healthcare providers that
attest to CMS.
(FAQ18257)
(FAQ18257)
less
For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, how should an eligible pro...- EPs, eligible hospitals, and CAHs can add the numerators and denominators calculated by each certified EHR system in ord... (more)
- EPs, eligible hospitals, and CAHs can add the numerators and denominators calculated by each certified EHR system in order to arrive at an accurate total for the numerator and denominator of the measure.
For objectives that require an action to be taken on behalf of a percentage of "unique patients," EPs, eligible hospitals, and CAHs may also add the numerators and denominators calculated by each certified EHR system in order to arrive at an accurate total for the numerator and denominator of the measure. Previously CMS had advised providers to reconcile information so that they only reported unique patients. However,
because it is not possible for providers to increase their overall percentage
of actions taken by adding numerators and denominators from multiple systems,
we now permit simple addition for all meaningful use objectives.
Please keep in mind that patients whose records are not maintained in certified EHR technology will need to be added to denominators whenever applicable in order to provide accurate numbers.
To report clinical quality measures, EPs who practice in multiple locations that are equipped with certified EHR technology should generate a report from each of those certified EHR systems and then add the numerators, denominators, and exclusions from each generated report in order to arrive at a number that reflects the total data output for patient encounters at those locations. To report clinical quality measures, eligible
hospitals and CAHs that have multiple systems should generate a report from
each of those certified EHR systems and then add the numerators, denominators,
and exclusions from each generated report in order to arrive at a number that
reflects the total data output for patient encounters in the relevant
departments of the eligible hospital or CAH (e.g., inpatient or emergency
department (POS 21 or 23)
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms
Keywords: FAQ10843
Updated 5/12/2016
(FAQ3609)
less
Are expenses for diagnostic psychological and neuropsychological tests subject to the payment limitation fo...- In most cases, expenses for diagnostic p... (more)
- In most cases, expenses for diagnostic psychological tests and neuropsychological tests are not subject to the payment limitation on certain outpatient mental health treatment services. The outpatient mental health treatment limitation (the limitation) is the payment limitation on treatment services for mental, psychoneurotic and personality disorders as authorized under section 1833(c) of the Social Security Act. However, the limitation does apply to diagnostic psychological and neuropsychological tests when these tests are performed to evaluate a patient’s progress during treatment rather than to establish or confirm the patient’s diagnosis. (See section 210.1, Chapter 12 of the Medicare Claims Processing Manual, Pub.100-04).
(FAQ2421)
less
How can a provider meet the “Protect Electronic Health Information” core objective in the Electronic He...- To meet the “Protect Electronic Health Information” core objective for Stage 1, eligible professionals (EP), eligibl... (more)
- To meet the “Protect Electronic Health Information” core objective for Stage 1, eligible professionals (EP), eligible hospitals or critical access hospitals (CAH) must conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1) and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process.
In Stage 2, in addition to meeting the same security risk analysis requirements as Stage 1, EPs and hospitals will also need to address the encryption and security of data stored in the certified EHR technology (CEHRT).
These steps may be completed outside or the EHR reporting period time frame but must take place no earlier than the start of the EHR reporting year and no later than the provider attestation date. For example, a EP who is reporting Meaningful Use for a 90-day EHR reporting period may complete the appropriate security risk analysis requirements outside of this 90-day period as long as it is completed no earlier than January 1st of the EHR reporting year and no later than the date the provider submits their attestation for that EHR reporting period.
This meaningful use objective complements but does not impose new or expanded requirements on the HIPAA Security Rule. In accordance with the requirements under (45 CFR 164.308(a)(1)(ii)), providers are required to conduct an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (ePHI). Once the risk analysis is completed, providers must take any additional “reasonable and appropriate” steps to reduce identified risks to reasonable and appropriate levels.
Please note that a security risk analysis or review needs to be conducted during each EHR reporting year for Stage 1 and Stage 2 of meaningful use to ensure the privacy and security of their patients’ protected health information.
For more information about completing a security risk analysis, please see the following resources: Security Risk Assessment Tip Sheet:
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/SecurityRiskAssessment_FactSheet_Updated20131122.pdf
https://www.cms.gov/Regulations-and-
Health Information Privacy and Security: A 10 Step Plan: http://www.healthit.gov/providers-professionals/ehr-privacy-security/10-step-plan"
Created 10/6/2014
Updated 11/5/2014
Archived 12/15/15
(FAQ10754)
less
What items or materials are considered educational materials and are not reportable transfers of value?- Educational materials and items that directly benefit patients, or are intended to be used by or with patients, are not ... (more)
- Educational materials and items that directly benefit patients, or are intended to be used by or with patients, are not reportable transfers of value. Additionally, the value of an applicable manufacturer’s services to educate patients regarding a covered drug, device, biological, or medical supply are not reportable transfers of value. For example, overhead expense, such as printing and time development of educational materials, which directly benefit patients or are intended for patient use are not reportable transfers of value. Key words: Open Payments, Sunshine Act
(FAQ8161)
less
How should modifier 59 be reported under the National Correct Coding Initiative (NCCI) program? - Modifier 59 is used to indicate a "distinct procedural service". (See Modifier 59 article at ... (more)
- Modifier 59 is used to indicate a "distinct procedural service". (See Modifier 59 article at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html for information about proper use of modifier 59.) Modifier 59 may not be appended to the evaluation and management (E&M) services Current Procedural Terminology (CPT) codes 99201-99499 or radiation treatment management CPT code 77427.
(FAQ11258)
less
Are there requirements specific to documentation in the
EHR Incentive Programs, including documentation in...- The Medicare and Medicaid EHR Incentive Programs does do no... (more)
-
The Medicare and Medicaid EHR Incentive Programs does do not
prescribe additional requirements related to documentation in electronic health
records. Providers and practitioners are required to adhere to all
applicable laws, regulations, program instructions, policies and procedures
specific to EHRs. Providers are expected to adhere to established
policies, procedures, and legalities specific to the integrity of EHRs found in
existing requirements and such as the Medicare physician fee
schedule.
Regarding medical student documentation, we refer providers
to the Medicare Claims Processing Manual (Internet-Only Manual Pub. 100-04,
Chapter 12, Section 100.1.1.B), physician fee schedule. Medicare
physician fee schedule rules state which states that students may document
services in the medical record. However, the documentation of an E/M service by
a student that may be referred to by the teaching physician is limited to
documentation related to the review of systems and/or past family/social
history. The teaching physician may not refer to a student's documentation of
physical exam findings or medical decision making in his or her personal note.
If the medical student documents E/M services, the teaching physician must
verify and re-document the history of present illness as well as perform and
re-document the physical exam and medical decision making activities of the service.
(IOM Pub. 100-04, chapter 12, section 100.1.1B).
For additional guidance and information related to medical
documentation please refer to the Program Medicaid Integrity Documentation
Matters Toolkit, available on the CMS Website at https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/documentation-matters.html
and the Complying With Medical Record Documentation Requirements Fact Sheet
available at MLN Connects webpage: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/mln-publications-items/icn909160.html.
(FAQ19061)
less
Can more than one CPT code for psychological or neuropsychological testing be billed on the same date of se...- Yes. If several different, clinically a... (more)
- Yes. If several different, clinically appropriate tests are administered on the same date to the same patient (whether by a physician/psychologist, technician or by computer), then the appropriate testing codes for psychological testing or neuropsychological testing can be billed together. More than one code can also be billed when several distinct tests are administered to the same patient on the same date of service via technician (96102/96119) or computer (96103/96120), and the physician/psychologist needs to integrate the separate interpretations and written reports for each of these tests into a comprehensive report.
(FAQ2423)
less
Does the exemption for reporting payments to medical residents also include payments to “Fellows”? - No. The final rule exempted payments to medical residents from the reporting requirements solely due to operational and ... (more)
- No. The final rule exempted payments to medical residents from the reporting requirements solely due to operational and data accuracy concerns regarding aggregation of payments or other transfers of value to residents, many of whom have neither a National Provider Identifier (NPI) nor a State professional license. Because these same concerns do not generally apply to physicians in Fellowship training, payments to Fellows are not exempt from the reporting requirements. Key words: Open Payments, Sunshine Act
(FAQ8372)
less
|
